RS 22:1133 Standard external review - Louisiana Statutes

§1133.  Standard external review

A.  Within sixty days after the date of receipt of a notice of a second level appeal adverse determination, the covered person whose medical care was the subject of such determination may, with the concurrence of the treating health care provider, file a request for an external review with the MNRO.  Within seven days after the date of receipt of the request for an external review, the MNRO shall provide the documents and any information used in making the second level appeal adverse determination to its designated independent review organization.  The independent review organization shall review all of the information and documents received and any other information submitted in writing by the covered person or the covered person's health care provider.  The independent review organization may consider the following in reaching a decision or making a recommendation:

(1)  The covered person's pertinent medical records.

(2)  The treating health care professional's recommendation.

(3)  Consulting reports from appropriate health care professionals and other documents submitted by the MNRO, covered person, or the covered person's treating provider.

(4)  Any applicable generally accepted practice guidelines, including but not limited to those developed by the federal government or  national or professional medical societies, boards, and associations.

(5)  Any applicable clinical review criteria developed exclusively and used by the MNRO that are within the appropriate standard for care, provided such criteria were not the sole basis for the decision or recommendation unless the criteria had been reviewed and certified by the appropriate licensing board of this state.

B.  The independent review organization shall provide notice of its recommendation to the MNRO, the covered person or his authorized representative, and the covered person's health care provider within thirty days after the date of receipt of the second level determination information subject to an external review, unless a longer period is agreed to by all parties.

Acts 1999, No. 401, §1, eff. Jan. 1, 2000; Redesignated from R.S. 22:3082 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.

NOTE:  See Acts 1999, No. 401, §2, regarding applicability.

NOTE:  Former R.S. 22:1133 redesignated as R.S. 22:1543 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.